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Alison is a 37 y

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Alison is a 37 y.o G5P1 (stillborn). Alison is married to Adam, and they are wheat farmers on a remote property west of Gilgandra. The drought for the last 5 years has been di?icult and Alison has no real support except for Adam and their closest neighbours who have a young family and live 50km away, and Adam’s family who live on the adjoining property 100km away. In 2017 Alison birthed a stillborn baby boy, Archie at 34 weeks gestation. Alison was diagnosed and treated for pre-eclampsia and antiphospholipid (APS) syndrome during that pregnancy. The post mortem investigations did not reveal the true cause of Archie’s death though he was noted to be growth restricted and had evidence of a small, infarcted placenta. After Archie’s birth Alison had postnatal depression and has since struggled with her mental health. Following the death of her mother last year, Alison now has clinically diagnosed anxiety and panic attacks and is taking prescribed low dose fluoxetine. Alison and Adam both feel that she really just has to now get on with everything, and try and stay focused on this pregnancy.
Medical and current obstetric history
Alison is usually physically well but has a history of urinary tract infections since her early 20s. She had a BMI of 18.0kg/m² at booking-in and Alison also smokes 10-15 cigarettes a day and has been unable to quit this pregnancy. Alison had a spontaneous conception of this pregnancy and was commenced on low dose Aspirin and Fragmin due to her previous history of 3 miscarriages between 8-10 weeks gestation and the presence of elevated APS antibody titres in her first antenatal pregnancy screen in this pregnancy. In view of her complex obstetric and medical history Alison was then referred to the maternal-fetal medicine team at Northview, your tertiary hospital, for review and case management after her baby was diagnosed with a Tetralogy of Fallot at her 18 week anatomical scan in Dubbo Base Hospital. An amniocentesis and paediatric cardiology review were then attended a week later at Northview and this baby has a normal karyotype. Plans were made for Alison to return to Sydney around 36 weeks to be near the Children’s Hospital for ongoing pregnancy management and the birth of her baby. Alison and Adam were linked to the Northview maternity social worker during that 18 week visit. The medical team at Dubbo are also monitoring Alison for any signs of pre-eclampsia and APS changes during this pregnancy.
Recent events
Alison has been in Dubbo Base Hospital for observation since 31+3 weeks due to an episode of threatened premature labour. Swabs and blood tests at that time were negative for infection and Alison was given a course of prophylactic IV antibiotics and IMI steroids. Whilst at Dubbo Base Hospital Alison was seen by her psychologist and the hospital’s social worker after midwifery staff reported concerns that Alison is not sleeping, has ruminative worry and they also have concerns for her mental health when she returns to Gilgandra after this baby is born. Alison also stated she is feeling really overwhelmed with everything and does not want to go to Sydney to have the baby especially now in these Covid-19 times.
At 32 weeks at 1000hrs Alison reported a frontal headache and some irregular uterine contractions, a CTG was satisfactory and her B.P was 150/90mmHg. On a speculum examination Alison’s cervix was a multi os, a fetal fibronectin test was positive, she was re-commenced on oral nifedipine, given oral labetalol and a decision was made to transfer Alison to Northview. Alison was transferred via air ambulance and arrived at midnight, she was alone on transfer and visibly upset on arrival. After spending the night in the birth unit and being treated for an episode of threatened preterm labour and evolving pre-eclampsia, she was transferred to the antenatal ward where she remained for the next 4 days. Tocolytic and anti-hypertensive medications were continued. Follow-up social work and psychology review was also attended.